New Patient Information Form

This information is kept strictly confidential. However, if you prefer to discuss this directly with the doctor please check the following box. 

Do you currently, or have you ever had any problems in the following systems: (If YES, please explain)

I certify that I have read and answered the above questions to the best of my knowledge. I authorize the eye doctor to release any information including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such eyecare to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the eye doctor or Vision Care Consultants any insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I acknowledge that I have received a notice of privacy from Vision Care Consultants.